POLST is part of advance care planning intended for people who are seriously ill or who have advanced frailty. It starts with a conversation between the patient and their health care provider regarding the patient’s medical condition, treatment options, and what the patient wants for care, and can lead to transferring patient treatment choices onto the POLST form.

With stakeholder guidance, we can build a much improved POLST Program where conversations between clinicians and patients, Health Care Agents and Guardians are at the center of the process. The POLST Program will include key implementation components such as:

• Professional training & education for clinicians & care teams
• Consumer education for adults, families, caregivers, legal advocates
• POLST orders that are immediately available 24/7 through an electronic registry, in particular to First Responders who require signed orders in order to provide selective or comfort-focused treatments.

Some of the specifics of the POLST Program implementation are still being determined. It is likely that there will be an extended period of time where paper MOLST forms are honored even after the implementation of the POLST registry to allow time for transition and to best support the care of our patients. POLST forms that are completed in the electronic registry will also be able to be printed. Provide your input into the process here.

While the e-registry is meant to allow POLST forms to be accessible at critical moments and moments of care transitions, individuals may still choose to keep a printed version of their POLST form in their home for easy reference for themselves, people who matter in their lives, and any care provider who may need it.

The State and the Auribus Consulting team are working hard to develop an implementation plan for successful rollout of the many pieces of the POLST Program (e.g. messaging, training, registry implementation, evaluation). The focus of the first phase of work has been to assess the current MOLST process from the perspective of key stakeholders, develop a future state blueprint of a POLST Program, and facilitate procurement of an electronic registry. The procurement documents are currently in the review process with the State. We will provide updates as they become available.

While the specifics of the implementation of the e-registry are still being determined, it is likely that there will be an extended period of time where MOLST forms are honored even after the implementation of the POLST registry to allow time for transition and to best support the care of our patients. Best practices for POLST include regularly verifying and updating MOLST/POLST forms with individuals when changing providers, at care transitions, when there is a substantial change in health status, and when a patient’s goals or care preferences change. These moments would present opportune times to transition a patient’s care preferences from a MOLST form into the POLST e-registry.

A core component of a successful POLST Program implementation will be training all stakeholders on the POLST form, the e-registry, and best practices around having conversations about what matters most to individuals, translating these conversations into care preferences, and honoring these preferences. We would love your input on what pieces of training are most important for your colleagues and care setting.

In April 2020 during the COVID-19 State of Emergency, the State waived the standard for written signatures by patients/ legal advocates on a MOLST form as it was not possible for patients and clinicians to have in-person planning conversations and sign a MOLST. At that time, the State authorized care providers to complete a MOLST form using Witnessed Verbal Consent to allow clinicians and patients to have goals of care discussions via telehealth and document patient choices.

As of May 12, 2021, EMS Protocols state the standard for a written signature by patients/legal advocates on the MOLST form has been reinstated and verbal is no longer accepted. However, there is an exception if the patient is in a licensed care facility. Please read Updated EMS Protocols here.

Importantly, a MOLST form completed with witnessed verbal consent from April 3, 2020 to May 11, 2021 will be considered VALID by EMS. We understand that this was a helpful tool for many, especially in a time of increased virtual visits. Many existing e-registry platforms allow for digital signatures, which can help with POLST completion during remote visits in certain situations. Please provide your input into this process.

No. HIPAA supports the free exchange of medical information necessary for treatment between clinicians and health systems. The current MOLST form states: “HIPAA permits disclosure of MOLST to health care providers as necessary for treatment." In Oregon, their form extends that statement to read “HIPAA permits disclosure of POLST to health care providers and electronic registry as necessary for treatment.”

A POLST form is a portable medical order. The POLST form tells all health care providers what a seriously ill or frail adult wants during an emergency and what their goals of care are given their current medical condition. The POLST form is signed by both the patient and the clinician. The POLST form travels with the patient and should be followed by licensed clinicians in all care settings. Massachusetts is adopting the National POLST form developed by National POLST.

Massachusetts DHS made the decision in 2019 to switch to the National POLST form. This form is based on best practices learned from research and mature programs around the country and is designed to simplify and better facilitate the translation of a patient's care preferences into medical orders. By adopting the new form, Massachusetts aligns with national standards and benefits from reciprocity with other states using the National form. The form has been adopted by Maine and New Hampshire, and it's being considered by Connecticut and Rhode Island. The National POLST form includes treatment orders for:

• Cardiopulmonary Resuscitation: Attempt or not attempt
• Scope of Treatment: Full Treatments, Selective Treatments, Comfort-Focused Treatments
• Medically Assisted Nutrition: Yes, No, Trial, Undecided

Here’s the sample POLST Form

No. POLST orders are NOT intended to replace communication between health professionals and patients, Health Care Agents, or Guardians. POLST orders should be accessed and followed when a patient is not able to speak for him or her self. For example, if a patient becomes unresponsive and 911 is called, EMS responders should access the patient’s POLST and follow the orders accordingly.

In contrast, when patients are able to speak for themselves and make their own medical decisions, POLST orders should be re-confirmed during transitions of care. For example, when a patient goes from a nursing care facility to a hospital, the admitting clinician should review the POLST form with the patient and confirm that the orders still represent what care the patient wants. When patients are not able to speak for themselves or make their own medical decisions, clinicians should re-confirm POLST orders with their Health Care Agent or Guardian.

No. POLST must always be voluntary for the patient, the Health Care Agent and Guardian. If you are forced or required to complete a POLST form, this violates patient self-determination, informed consent, and the principles of person and family-centered care. Patients have a right to participate in medical decision-making regarding their treatment plan, including the choice of saying they do not want a POLST form. Organizational policies and procedures in any care setting should never require adults to complete a POLST form.

Section A and B are designed to provide clarity for EMS providers who must be able to act quickly and decisively in an emergency. They proceed along the lines of BLS protocols:

Section A: Only if the patient has no pulse and is not breathing. Either Yes CPR, or No CPR. If the patient has a pulse and is breathing, move to Section B.

Section B: The patient has a pulse and is breathing, but is in crisis.

• If Full Treatments: transport the patient to hospital; if necessary, intubate the patient.
• If Selective Treatments: transport the patient to hospital; if necessary provide oxygen, non-invasive airway support, but do not intubate the patient.
• If Comfort-focused Treatments: provide oxygen, medication, and any other available treatment for comfort; do not intubate the patient. Transport the patient only if they cannot be kept comfortable where they are at.

Importantly, patients with an order to attempt CPR should also have an order for Full Treatment. Many patients who receive CPR will end up intubated and in the intensive care unit, which equals Full Treatments. It does not make sense to have an order for Selective Treatments that does not allow intubation, but instructs EMS to perform CPR, which includes intubation, if the patient is no longer breathing. Finally, an order for Comfort-focused Treatments and a goal of allowing natural death should not be combined with an order to attempt CPR.

While Full treatment combined with No CPR may seem incongruent, it is not. It means that all effective treatment efforts to prolong life should be provided including intubation and ICU care. However, if the patient loses their pulse or stops breathing, treatment should not be escalated to include CPR, or, at that point if they are not already intubated, intubation.